Codeployment of a percutaneous edge-to-edge mitral valve repair device and a ventriculoseptal defect occluder device to address complex mitral regurgitation with leaflet perforation

Abstract

An 80-year-old male with severe, complex mitral regurgitation (MR) after recent transcatheter aortic valve replacement presented in heart failure for percutaneous mitral valve repair and possible tricuspid valve repair. Transesopheageal echocardiography (TEE) demonstrated mixed Carpentier Types 1 and 2 components with annular dilation, two leaflet perforations, and excessive leaflet motion (P2 flail). There were three distinct MR jets appreciated reflecting a central coaptation defect and two posterior mitral valve leaflet perforations emanating from a cystic dilatation. Under TEE guidance transseptal puncture and percutaneous edge-to-edge mitral valve repair was performed with a MitraClip XTR device (Abbott, IL). A 10 mm Amplatzer Muscular VSD Occluder (Abbott, Abbott Park, IL) was deployed to close one of the perforations on the posterior leaflet with a significant reduction in MR severity. Attempts at crossing the remaining defect were unsuccessful and the procedure was concluded. The patient recovered uneventfully and transthoracic echocardiography on postoperative day (POD) 1 and again on POD 34 demonstrated normal systolic dominance on pulmonary venous Doppler interrogation, mild to moderate MR, and a mean transvalvular gradient of 5 mmHg. Both devices appeared firmly attached and stable. This is the first documented use of a VSD occluder device in this clinical scenario. Management of complex MR with an approach combining edge-to-edge repair for a central coaptation defect and leaflet flail with codeployment of a VSD occluder device to address a perforated leaflet is feasible and can achieve durable results.

Keywords: Amplatzer; MitraClip; transseptal; transvenous mitral valve repair.

Figure 1.

Screening transesophageal echocardiography exam identified two posterior leaflet perforations. Significant color flow and coanda effect were noted through one perforation.

Figure 2.

Second, smaller posterior leaflet perforation is noted on screening echocardiography.

Figure 3.

Pre-intervention 3D en face view of the mitral valve oriented in the “surgeon’s view.” There is cystic dilatation of the posterior mitral valve leaflet.

Figure 4.

Pre-intervention 3D model of the mitral valve demonstrating cystic dilatation of the posterior MVL.

Figure 5.

Mid-esophageal view demonstrating one of the large eccentric jets originating from the posterior MVL perforation obtained shortly after edge-to-edge repair was achieved. The previously noted central MR jet is no longer appreciated.

Figure 6.

Post-intervention mid-esophageal mitral commissural view with the MitraClip XTR device noted at A2/P2 and the 10mm Amplatzer muscular VSD occluder appreciated posterio-medially.

Figure 7.

3D en face view of the mitral valve demonstrating the double-orifice mitral valve with the MitraClip XTR device appreciated bridging A2/P2 and the 10mm Amplatzer muscular VSD occluder positioned just medial to the MitraClip on the posterior MVL.